Summary

Initiatives aimed at reducing Emergency Department (ED) wait times and improved community
health initiatives are major priorities in Canada. Three of the most common chronic diseases
worldwide are Diabetes Mellitus (DM), Congestive Heart Failure (CHF) and Chronic Obstructive
Pulmonary Disease (COPD). These diseases are on the rise and currently cost the Canadian
health care system billions of dollars every year including the cost of hospitalizations and
ED visits. The existing health care system does not have the resources and manpower to
effectively care for these patients in the future.

Paramedics are currently employed to provide Emergency Medical Services in remote, rural and
urban settings in Canada.

They are highly trained health care practitioners that are mobile in the community and
currently work in a physician medically delegated act model and therefore are positioned to
take on new collaborative roles to deliver patient care in the community setting. Increased
community paramedic care could decrease the utilization of the health care system resources
for patients with chronic disease. Using a randomized control trial design we will attempt
to answer the question of whether whether non-emergency community paramedics conducting home
visits to undertake assessments and evidence-based treatments of patients in partnership
with family doctors will decrease the rate of patient hospitalization.

Study Design

Patients randomized to the control group will continue to receive usual care from their Family Health Care Team. Usual care includes physician assessment and treatment and periodic augmentation of care in the community (CCAC or case manager, nurse practitioner) at the discretion of the treating physician.

The intervention will consist of an initial visit and 3 follow-up visits at 3 month intervals over one year by a paramedic who has received additional training in chronic disease management, in addition to routine usual care and any additional visits prompted by the patient, the paramedic or the Family Health Care Team.

community paramedicine

Primary Outcomes

Measure

Hospital admissions per patient

time frame:
maximum 2 years

Secondary Outcomes

Measure

Health Resource Utilization

time frame:
maximum 2 years

Cost Effectiveness

time frame:
maximum 2 years

Eligibility Criteria

Male or female participants at least 18 years old.

Inclusion Criteria:
Residents of the region of York, Ontario, 18 years of age or older, diagnosed at any point
in time with COPD, CHF, or DM and identified by the Family Health Care Team as high risk
for admission.
Exclusion Criteria:
Residents of long-term care facilities or if have cognitive impairment, uncontrolled
psychiatric disease or language barriers that would make it difficult to understand the
consent and communicate with the paramedic during the scheduled visits, unless the
individual with power of attorney for personal care consented and agreed to be at each
visit.

Additional Information

Official title

The Expanding Paramedicine in the Community (Study)

Principal investigator

Laurie Morrison, MD, MSc, FRCPC

Description

Imagine if we could leverage existing infrastructure to enhance how we better manage and
support patients with chronic disease in the community? Three of the most common chronic
diseases worldwide are Diabetes Mellitus (DM), Congestive Heart Failure (CHF) and Chronic
Obstructive Pulmonary Disease (COPD). These diseases are on the rise and currently cost the
Canadian health care system billions of dollars every year including the cost of unnecessary
hospitalizations and ED visits. The current structure of the health care system does not
have the capacity to effectively care for these patients in the future. Paramedics are
currently employed 24-7 to provide Emergency Medical Services (EMS) in urban, rural and
settings across Canada. They are highly trained health care practitioners that are connected
to and mobile in the community and currently work in a medically delegated act model with
physicians where they regularly rely on independent judgment giving them a significant
advantage in assessing patients. The evidence already tells us that collaborative Chronic
Care Models can improve patient outcomes and decrease overall health care utilization. What
if we leveraged this incredible resource to enhance patient care in the community setting?
We hypothesize that training paramedics in chronic disease management and having them
conduct home visits to assess and treat patients under medical delegation of the patients'
primary care physicians will reduce the rate of acute care hospitalization and, ED visits,
EMS utilization, and Family Health Team (FHT) utilization for COPD, DM and CHF patients.
So how do we find out if it works? We propose a randomized controlled trial (Level 1
evidence) to rigorously study the effectiveness of community paramedicine model versus
standard care. The primary study question is whether non-emergency community paramedics
conducting home visits to undertake assessments and evidence-based treatments of patients
under the medical delegation of primary care physicians will decrease the rate of
hospitalization for chronic disease patients. Our intervention will be applied in select
Ontario Family Health Team (FHT) patients diagnosed with COPD, CHF and DM. We plan to
randomize 695 patients: patients randomized to the intervention group will be assessed and
treated during home visits by community paramedics. Patients randomized to the control group
will continue to receive usual care from the participating Family Health Teams. The number
of hospitalizations, hospital length of stay, ED visits, EMS utilization and
cost-effectiveness will be compared using existing administrative databases. We have been
doing a feasibility trial since March of 2013 to confirm our recruitment and data collection
approaches.
The intent of the Partnerships for Health System Improvement (PHSI) program is to strengthen
Canada's health care system through collaborative, applied and policy-relevant research. Our
project has been developed in strong partnership with Centennial College; Central Community
Care Access Centre; York Region Emergency Medical Services; Health For All Family Health
Team; Markham Family Health Team; Rescu, Li Ka Shing Knowledge Institute, St. Michael's
Hospital; and the Sunnybrook Centre for Prehospital Medicine. We have also partnered
directly with the Primary Care Branch of the Ministry of Health and Long Term Care to ensure
a fruitful integrated knowledge translation plan at the policy level. By engaging all of the
key stakeholders upfront we have already created the necessary linkages to make this health
system innovation possible.
If found to be effective, the simplicity of the community paramedicine model allows it to be
scalable in various ways for EMS services across the country. It could also be expanded to
include management of several other conditions. Funding is only getting tighter and health
care capacities will be increasingly challenged in the coming years - innovation in how we
use existing resources is the future of health system improvement. Community paramedicine is
a perfect example of this type of innovation and our project will provide the evidence
needed by decision makers and knowledge users to significantly impact primary care policy
making for the future.

Trial information was received from ClinicalTrials.gov and was last updated in April 2016.

Information provided to ClinicalTrials.gov by St. Michael's Hospital, Toronto.